Week 15: Transfusion Reactions & Transmitted Infections PDF

TRANSFUSION REACTIONS 15 & Transfusion transmitted infections TRANSFUSION REACTIONS Adverse effect that occurs as the result of administration of blood or blood components IMMEDIATE EFFECTS 1. Immunologic Effects A. Acute HTR Hemolysis with symptoms due to red cell incom...

TRANSFUSION REACTIONS 15 & Transfusion transmitted infections TRANSFUSION REACTIONS Adverse effect that occurs as the result of administration of blood or blood components IMMEDIATE EFFECTS 1. Immunologic Effects A. Acute HTR Hemolysis with symptoms due to red cell incompatibility B. Febrile non-hemolytic transfusion reaction (FNHTR) Antibody to leukocyte antigens Increase in temperature of 1'C or more that is associated with transfusion and cannot be explained by any other medical condition C. Anaphylaxis Antibody to IgA Occur only after the infusion of only few millimeters of blood Due to the reaction between anti-IgA and igA in transfused products D. Allergy or Urticaria Antibody to plasma proteins Reaction between recipient antibody and transfused donor plasma proteins E. Transfusion-related acute lung injury (TRALI) or Non- cardiac pulmonary edema Antibody to leukocytes or complement activation 2. Non-Immunologic Effects A. Transfusion-Associated Sepsis (TAS) or Marked fever with shock Bacterial contamination Bacterial Organisms associated with TAS Gram Positive: Staphylococcus species Streptococcus species Bacillus species Gram Negative: Serratia species Yersinia species Acinetobacter species Escherichia species Pseudomonas species Providencia species Delayed Effects 1. Immunologic Effects A. Delayed HTR Anamnestic antibody to red cell antigens B. Transfusion-associated graft-versus-host disease (TA- GVHD) Engraftment of transfused functional lymphocytes C. Post-transfusion purpura Development of antiplatelet antibody Individuals primarily at risk have been previously immunized to platelet antigens through pregnancy and/or previous transfusion D. Alloimmunization Exposure to antigens of donor origin 2. non-Immunologic Effects A. Iron overload or Transfusion-assoc hemosiderosis Multiple transfusions B. Hepatitis NANB, occasionally C. Acquired immune deficiency syndrome Host response to agent in donor blood D. Protozoan infection Malaria parasites IMMEDIATE EFFECTS HEMOLYTIC Fever, chills, Avoid human error flushing, nausea, (confirmation of dyspnea, chest pain, recipient an donor) flank pain, Adequate renal Use well-written hypotension, shock, perfusion, induce procedure manuals hemoglobinemia, diuresis, treat shock Use highly trained hemoglobinuria, DIC, and manage clinical and renal failure disseminated laboratory staff In anesthetized or intravascular Use quality unconscious patient, coagulation (DIC) assurance and/or may see hypotension, quality improvement hemoglobinuria, program anuria, bleeding  Febrile non-hemolytic Premedicate with antipyretics Administer Transfuse leukocyte Chills, fever antipyretics reduced products who have experienced 2 or more FNHTR Urticarial Administer In patients who have antihistamine while suffered multiple Hives blood flow is urticaria reactions, slowed or stopped pretreat with antihistamines  Anaphylactic Flushing of the skin, abrupt hypertension Give immediate Transfuse washed followed by treatment with RBCs or platelets or hypotension, epinephrine, IV frozen RBCs and substernal pain, corticosteroids and plasma from IgA- dyspnea, nausea, O2 therapy may be deficient donors abdominal, cramps, indicated emesis, diarrhea  Transfusion-related acute lung injury (TRALI) Use proper donor selection (recommended that Chills, fever, RBCS from donors nonproductive implicated in TRALI cough, dyspnea, Give respiratory reaction who have cyanosis, bilateral support, steroids circulatinG pulmonary edema, and diuretics granulocyte or severe hypoxemia, lymphocyte hypotension antibodies be administered as deglycerolized or washed RBCs)  Bacterial contamination Carefully monitor each step of blood Fever, chills, Give IV antibiotics, collection, storage hypotension, fluids, and and transfusion to tachycardia, shock vasopressors to prevent (warm type), maintain blood introduction of hemoglobinemia, pressure, bacteria into unit hemoglobinuria, appropriate therapy Carefully inspect renal failure, DIC for DIC (if present) blood products before distribution for transfusion  Transfusion-associateD circulatory overload (TACO) Identify susceptible individuals and Anxiety, restlessness, Administer diuretics, transfuse blood coughing, place patients in components slowly tachycardia, upright position (02 (1mL/kg body dyspnea, cyanosis, by mask, IV weight/hr) and in severe headache, morphine, most concentrated signs of congestive phlebotomy of 200- form available heart failure, 400mL of blood (when necessary, peripheral edema necessary aliquot donor unit and refrigerate unused portion/s at 1°-6°C)  Physical or chemical hemolysis Adhere to established Asymptomatic Generally none protocols outlined hemoglobinuria needed; serious in laboratory policy (hemoglobinemia, DIC sequelae need to be and procedure and renal failure treated immediately manual for proper are rare) preparation, storage and transfusion of blood components Delayed TRANSFUSION REACTIONS HEMOLYTIC Check patient's previous records Make notation of Treatment is rarely patient's antibody Fever, decreased necessary; give status in permanent hemoglobin, mild antigen-negative laboratory record jaundice blood for Administer antigen subsequent negative blood for transfusions all subsequent transfusions (even if antibody screen in negative)  Post-transfusion purpura Difficult to prevent Use corticosteroids, Clinicians should Profound self- therapeutic plasma have thorough limiting exchange, high dose patient history and thrombocytopenia, intravenous history of any generalized purpura immunoglobulins adverse reactions to previous transfusions  Transfusion-associated graft-versus-host disease ACUTE: fever, diffuse skin rash, diarrhea infection, abnormal Irradiate all blood liver function, components pancytopenia, ACUTE: no adequate containing usually fatal therapy lymphocytes with a CHRONIC: fever, dose of 25 Gy before scleroderma-like CHRONIC: no adequate transfusion to disease, Sicca therapy susceptible syndrome, individuals interstitial Pneumonitis, malabsorption  Transfusion-induceD hemosiderosis Muscle weakness, weight loss, mild jaundice, fatigue, Administering Super or cardiac arrhythmias, deferroxamine hypertransfusion of mild diabetes, neocytes growth, retardation in children  Disease transmission Use volunteer blood supply Do serologic testing of all donor units Fever, fatigue, Notify facility for Require medical and lymphadenopathy, drawing blood, physical history of adenopathy, malaise, quarantine all potential donors arthralgia, Icterus, components in Give HBV vaccine to hemolysis (in storage prepared all healthcare malaria) from same unit workers Administer hepatitis prophylaxis after exposure to HBsAg positive blood TRANFUSION REACTION INVESTIGATION The transfusion must be stopped for any reaction. The IV line must be kept open with crystalloid in case immediate treatment is necessary to overcome hypotension. The attending physician and the blood bank must be notified as soon as possible. WORKUP A clerical check of the compatibility tag on the blood bag, the blood bag label, and the patient identification for discrepancies. Examination of pretransfusion clotted blood specimen, an EDTA anticoagulated post-transfusion blood specimen (perform a DAT), and the blood bag. Perform a Gram's stain on the blood in the bag and culture, if necessary, to determine the presence of bacterial contamination. Repeat the ABO/ Rh typing, antibody screen, and the crossmatch to see if a patient antibody is directed against donor cells. If antibody is suspected, an RBC panel should be performed for identification of the antibody. Examination of the post-transfusion urine. Determination on post-transfusion anticoagulated specimen of prothrombin time, partial thromboplastin time (PTT), platelet count, fibrinogen, fibrin split products, if DIC is suggested. Measurement of hemoglobin and/or hematocrit at frequent intervals if hemolysis is observed. TRANSFUSION-TRANSMITTED DISEASES Infectious Disease Transmission HBsAg (before 1980) HBc antibody (1986) HCV antibody (1990); HCV NAT testing (1999 under IND/licensed in 2002) HIV 1/2 antibody (HIV-1: 1985; HIV-2: 1992) HIV-1 p24 antigen (1996, discontinued 2002); HIV-1 NAT testing (1999 under IND/licensed in 2002) HTLV-1/1I antibody (1997) Syphilis (before 1980) Cytomegalovirus Trypanosoma cruzi antibody/Chaga's disease (2007/currently not mandated) West Nile Virus NAT testing (2003 under IND/licensed in 2007) Donor units must be tested for specific test for Syphilis (STS) Anti-HIV-1/2 HIV-antigen anti-HTLV1/ll HBsAg anti-HBc anti-HCV methods A. hbv chemiluminescent immunoassay (ChLIA) or enzyme immunoassay (EIA) Confirmatory: Neutralization B. hcv ChLIA or EIA Confirmatory: RIBA or recombinant immunoblot assay C. HIV 1/2 Confirmatory for HIV-1: immunofluorescence assay (IFA) or Western blot Confirmatory for HIV-2: EIA D. HTLV-I/II ChLIA or EIA IFA or line immunoblot (confirmatory or supplemental assays) E. Syphilis: microhemagglutination or EIA (for antibodies) solid-phase red cell adherence or particle agglutination (non-Treponemal serologic test) Confirmatory: Treponema pallium antigen-specific immunofluorescence or agglutination assays F. West Nile Virus transcription-mediated amplification (TMA) or polymerase chain reaction (PCR) G. Trypanosoma cruzi ChLIA or EIA RIPA or radioimmunoprecipitation assay (confirmatory or supplemental assays)